scholarly journals Contralateral posterior interhemispheric approach to deep medial parietooccipital vascular malformations: surgical technique and results

2018 ◽  
Vol 129 (1) ◽  
pp. 198-204 ◽  
Author(s):  
Jan-Karl Burkhardt ◽  
Ethan A. Winkler ◽  
Michael T. Lawton
Keyword(s):  
Vascular Malformations ◽  
Angle Of Attack ◽  
Patient Positioning ◽  
Safe Alternative ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Alternative Approach ◽  
Scale Scores ◽  
Lateral Margins

OBJECTIVEDeep medial parietooccipital arteriovenous malformations (AVMs) and cerebral cavernous malformations (CCMs) are traditionally resected through an ipsilateral posterior interhemispheric approach (IPIA), which creates a deep, perpendicular perspective with limited access to the lateral margins of the lesion. The contralateral posterior interhemispheric approach (CPIA) flips the positioning, with the midline positioned horizontally for retraction due to gravity, but with the AVM on the upper side and the approach from the contralateral, lower side. The aim of this paper was to analyze whether the perpendicular angle of attack that is used in IPIA would convert to a parallel angle of attack with the CPIA, with less retraction, improved working angles, and no significant increase in risk.METHODSA retrospective review of pre- and postoperative clinical and radiographic data was performed in 8 patients who underwent a CPIA.RESULTSThree AVMs and 5 CCMs were resected using the CPIA, with an average nidus size of 2.3 cm and CCM diameter of 1.7 cm. All lesions were resected completely, as confirmed on postoperative catheter angiography or MRI. All patients had good neurological outcomes, with either stable or improved modified Rankin Scale scores at last follow-up.CONCLUSIONSThe CPIA is a safe alternative approach to the IPIA for deep medial parietooccipital vascular malformations that extend 2 cm or more off the midline. Contralaterality and retraction due to gravity optimize the interhemispheric corridor, the surgical trajectory to the lesion, and the visualization of the lateral margin, without resection or retraction of adjacent normal cortex. Although the falx is a physical barrier to accessing the lesion, it stabilizes the ipsilateral hemisphere while gravity delivers the dissected lesion through the transfalcine window. Patient positioning, CSF drainage, venous preservation, and meticulous dissection of the deep margins are critical to the safety of this approach.

Contralateral Anterior Interhemispheric Approach to Medial Frontal Arteriovenous Malformations: Surgical Technique and Results

2017 ◽  
Vol 13 (4) ◽  
pp. 413-420 ◽  
Author(s):  
Ahmad Hafez ◽  
Kunal P. Raygor ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Angle Of Attack ◽  
Lateral Margin ◽  
Safe Alternative ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Anterior Interhemispheric Approach ◽  
Interhemispheric Fissure ◽  
Radiographic Data

Abstract BACKGROUND: Medial frontal arteriovenous malformations (AVMs) require opening the interhemispheric fissure and are traditionally accessed through an ipsilateral anterior interhemispheric approach (IAIA). The contralateral anterior interhemispheric approach (CAIA) flips the positioning with the midline still positioned horizontally for gravity retraction, but with the AVM on the upside and the approach from the contralateral, dependent side. OBJECTIVE: To determine whether the perpendicular angle of attack associated with the IAIA converts to a more favorable parallel angle of attack with the CAIA. METHODS: The CAIA was used in 6 patients with medial frontal AVMs. Patients and AVM characteristics, as well as pre- and postoperative clinical and radiographic data, were reviewed retrospectively. RESULTS: Four patients presented with unruptured AVMs, with 5 AVMs in the dominant, left hemisphere. The lateral margin was off-midline in all cases, and average nidus size was 2.3 cm. All AVMs were resected completely, as confirmed by postoperative catheter angiography. All patients had good neurological outcomes, with either stable or improved modified Rankin Scores at last follow-up. CONCLUSIONS: This study demonstrates that the CAIA is a safe alternative to the IAIA for medial frontal AVMs that extend 2 cm or more off-midline into the deep frontal white matter. The CAIA aligns the axis of the AVM nidus parallel to the exposure trajectory, brings its margins in view for circumferential dissection, allows gravity to deliver the nidus into the interhemispheric fissure, and facilitates exposure of the lateral margin for the final dissection, all without resecting or retracting adjacent normal cortex.

Posterior Interhemispheric Approach: Surgical Technique, Application to Vascular Lesions, and Benefits of Gravity Retraction

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-41-ONS-49 ◽  
Author(s):  
John H. Chi ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Artery Aneurysm ◽  
Occipital Lobe ◽  
Vascular Lesions ◽  
Arteriovenous Fistulae ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Occipital Lobes ◽  
Posterior Midline

Abstract OBJECTIVE: To review an experience with the posterior interhemispheric approach applied to vascular lesions in the posterior midline, to examine the effects of patient position and gravity retraction of the occipital lobe, and to identify circumstances requiring increased exposure by sectioning the falx and tentorium. METHODS: During a 6.5-year period, 46 posterior interhemispheric approaches were performed to treat 28 arteriovenous malformations, 10 dural arteriovenous fistulae, seven cavernous malformations, and one posterior cerebral artery aneurysm. Twenty-three patients were positioned prone and 23 patient were positioned laterally. RESULTS: A standard posterior interhemispheric approach was used in 38 patients, and the occipital bitranstentorial/falcine approach was used in seven patients. A contralateral occipital transfalcine approach was used with one thalamic cavernous malformation. All lesions were resected completely and/or obliterated angiographically, with good neurological outcomes in 83% of patients and no operative mortality. Blood loss was lower, operative durations were shorter, postoperative cerebral edema was decreased, and visual outcomes were improved in patients positioned laterally. CONCLUSION: The posterior interhemispheric approach, without additional dural cuts, is appropriate for most vascular lesions in the posterior midline. Gravity retracts the occipital lobes when patients are positioned laterally, enhancing operative exposure and reducing morbidity. Extension of the posterior interhemispheric approach to a transtentorial or transfalcine approach is required for falcotentorial dural arteriovenous fistulae and vein of Galen arteriovenous malformations, but is not usually necessary with cavernous malformations or other arteriovenous malformations.

scholarly journals Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review

2021 ◽  
pp. svn-2020-000608
Author(s):  
Da Li ◽  
Jing-Jie Zheng ◽  
Jian-Cong Weng ◽  
Pan-Pan Liu ◽  
Ze-Yu Wu ◽  
...  
Keyword(s):  
Neurological Status ◽  
Neurological Deficits ◽  
Developmental Venous Anomaly ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Scale Scores ◽  
Risk Patients ◽  
History Of ◽  
Lost To Follow Up

BackgroundHaemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs and to identify the adverse factors associated with worsened outcomes.MethodsFrom 2009 to 2015, 698 patients (321 women) with brainstem CMs were entered into the prospective cohort after excluding patients lost to follow-up (n=43). All patients were registered, clinical data were collected and scheduled follow-up was performed.ResultsAfter a median follow-up of 60.9 months, prospective haemorrhages occurred in 167 patients (23.9%). The mean modified Rankin Scale scores at enrolment and at censoring time were 1.6 and 1.2. Neurological status was improved, unchanged and worsened in 334 (47.9%), 293 (42.0%) and 71 (10.2%) patients, respectively; 233 (33.4%) recovered to normal levels. Lesions crossing the axial midpoint (relative risk (RR) 2.325, p=0.003) and developmental venous anomaly (DVA) (RR 1.776, p=0.036) were independently significantly related to worsened outcomes. The percentage of worsened outcomes was 5.3% (18 of 337) in low-risk patients (neither DVA nor crossing the axial point) and increased to 26.0% (13 of 50) in high-risk patients (with both DVA and crossing the axial point). The percentage of worsened outcomes significantly increased as the number of prospective haemorrhages increased (from 1.5% (8 of 531, if 0 prospective ictus) to 37.5% (48 of 128, if 1 ictus) and 38.5% (15 of 39, if >1 ictus)).ConclusionsThe neurological outcomes of untreated brainstem CMs were improved/unchanged in majority of patients (89.8%) with a fatality rate of 1.7% in our cohort, which seemed to be favourable. Radiological features significantly predicted worsened outcomes. Our results provide evidence for clinical consultation and individualised treatment. The referral bias of our cohort was underlined.

Unexpected Binding of Tozuleristide “Tumor Paint” to Cerebral Vascular Malformations: A Potentially Novel Application of Fluorescence-Guided Surgery

Neurosurgery ◽  
2021 ◽  
Author(s):  
Andrew J Kobets ◽  
David Nauen ◽  
Amy Lee ◽  
Alan R Cohen
Keyword(s):  
Near Infrared ◽  
Vascular Malformations ◽  
Cns Tumors ◽  
Matrix Metalloproteinase 2 ◽  
Cerebrovascular Lesions ◽  
Cavernous Malformations ◽  
Guided Surgery ◽  
Fluorescence Guided Surgery ◽  
Cerebral Vascular Malformations ◽  
Cerebral Vascular

Abstract BACKGROUND Fluorescence-guided surgery (FGS) is under investigation as a means to improve the extent of resection for primary central nervous system (CNS) tumors. Tozuleristide, known also as “Tumor Paint,” is an investigational tumor-targeting agent covalently conjugated to a derivative of the fluorescent dye indocyanine green. OBJECTIVE To report the finding of avid intraoperative fluorescence of tozuleristide on cerebral vascular malformations. METHODS Our institution is participating in a phase 2/3 study of intraoperative near-infrared fluorescence detection of pediatric primary CNS tumors in patients receiving intravenous tozuleristide and imaged with the Canvas system. Our site enrolled 2 patients with intracranial lesions, suspected preoperatively of possibly being gliomas that proved to be cavernous vascular malformations after resection. RESULTS Each lesion had a dark blue mulberry appearance and each fluoresced avidly with tozuleristide. Each was completely resected, and the patients recovered without deficit. Pathological assessment showed cavernous angioma for both cases. Tozuleristide fluorescence is postulated to result from binding to matrix metalloproteinase-2 and annexin A2, and literature review demonstrates expression of both these ligands on multiple cerebrovascular lesions, including cavernous malformations. CONCLUSION This finding deserves further investigation to determine if tozuleristide “Tumor Paint” may have a wider role in the identification of non-neoplastic intracranial pathologies.

scholarly journals An alternative approach for complicated prosthetic aortic valve endocarditis

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Dimos Karangelis ◽  
Argyris Krommydas ◽  
Fotios A. Mitropoulos
Keyword(s):  
Surgical Treatment ◽  
Prosthetic Valve ◽  
Prosthetic Valve Endocarditis ◽  
Pericardial Patch ◽  
Safe Alternative ◽  
Case Presentation ◽  
Prosthetic Aortic Valve ◽  
Alternative Approach ◽  
Sutureless Valve ◽  
Valve Implantation

Abstract Background Surgical treatment of prosthetic valve endocarditis (PVE) with destruction of the aortic root and aortomitral continuity is demanding even in experienced hands. Case presentation Herein, we describe a case of a 71-year-old female patient who presented with PVE that was further complicated by a fistulous abscess cavity. The patient underwent removal of the dehisced prosthetic valve, radical annular debridement, reconstruction of the aortomitral curtain with a pericardial patch as a patch exclusion technique and implantation of a sutureless valve. Conclusion Patch exclusion technique, followed by sutureless valve implantation, might represent a feasible and safe alternative for the surgical treatment of complicated PVE.

scholarly journals Transcriptome-wide Profiling of Cerebral Cavernous Malformations Patients Reveal Important Long noncoding RNA molecular signatures

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Santhilal Subhash ◽  
Norman Kalmbach ◽  
Florian Wegner ◽  
Susanne Petri ◽  
Torsten Glomb ◽  
...  
Keyword(s):  
Noncoding Rna ◽  
Vascular Malformations ◽  
Cerebrovascular Disorders ◽  
Gene Set Enrichment Analysis ◽  
Differentially Expressed ◽  
Low Flow ◽  
Pcr Analysis ◽  
Cerebral Cavernous Malformations ◽  
Cavernous Malformations ◽  
Non Coding Rnas

AbstractCerebral cavernous malformations (CCMs) are low-flow vascular malformations in the brain associated with recurrent hemorrhage and seizures. The current treatment of CCMs relies solely on surgical intervention. Henceforth, alternative non-invasive therapies are urgently needed to help prevent subsequent hemorrhagic episodes. Long non-coding RNAs (lncRNAs) belong to the class of non-coding RNAs and are known to regulate gene transcription and involved in chromatin remodeling via various mechanism. Despite accumulating evidence demonstrating the role of lncRNAs in cerebrovascular disorders, their identification in CCMs pathology remains unknown. The objective of the current study was to identify lncRNAs associated with CCMs pathogenesis using patient cohorts having 10 CCM patients and 4 controls from brain. Executing next generation sequencing, we performed whole transcriptome sequencing (RNA-seq) analysis and identified 1,967 lncRNAs and 4,928 protein coding genes (PCGs) to be differentially expressed in CCMs patients. Among these, we selected top 6 differentially expressed lncRNAs each having significant correlative expression with more than 100 differentially expressed PCGs. The differential expression status of the top lncRNAs, SMIM25 and LBX2-AS1 in CCMs was further confirmed by qRT-PCR analysis. Additionally, gene set enrichment analysis of correlated PCGs revealed critical pathways related to vascular signaling and important biological processes relevant to CCMs pathophysiology. Here, by transcriptome-wide approach we demonstrate that lncRNAs are prevalent in CCMs disease and are likely to play critical roles in regulating important signaling pathways involved in the disease progression. We believe, that detailed future investigations on this set of identified lncRNAs can provide useful insights into the biology and, ultimately, contribute in preventing this debilitating disease.

Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations

2018 ◽  
Vol 15 (4) ◽  
pp. 404-411 ◽  
Author(s):  
Justin Mascitelli ◽  
Jan-Karl Burkhardt ◽  
Sirin Gandhi ◽  
Michael T Lawton
Keyword(s):  
Intraoperative Complications ◽  
Occipital Lobe ◽  
Senior Author ◽  
Pineal Region ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Posterior Thalamus ◽  
Neurological Outcomes ◽  
The Right ◽  
Brain Retraction

Abstract BACKGROUND Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium. OBJECTIVE To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs. METHODS From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient. RESULTS All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively. CONCLUSION This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.

Unique enlarging cavernous malformation secondary to abnormal arteriovenous shunting through an associated developmental venous anomaly

2021 ◽  
pp. 197140092110428
Author(s):  
Nimisha Parikh ◽  
Richard Williamson ◽  
Matthew Kulzer ◽  
Albert Sohn ◽  
Warren M Chang ◽  
...  
Keyword(s):  
Unusual Case ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Venous Hypertension ◽  
Developmental Venous Anomaly ◽  
Venous Anomaly ◽  
Arteriovenous Shunting ◽  
Cavernous Malformations ◽  
Progressive Growth

Cavernous malformations are angiographically occult vascular malformations. They are often associated with a developmental venous anomaly through poorly understood mechanisms. We present an unusual case of a gradually enlarging cavernous malformation associated with a developmental venous anomaly with arteriovenous shunting, suggesting venous hypertension or reflux as a potential cause of progressive growth.

Abstract 1122‐000135: Application of the Berenstein‐DeLeacy Grading Scale to Assess Treatment Outcome in Orbital Lymphatic Malformations

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Reade De Leacy ◽  
Maximilian J Bazil ◽  
Neha Siddiqui ◽  
Stavros Matsoukas ◽  
Tomoyoshi Shigematsu ◽  
...  
Keyword(s):  
Granulation Tissue ◽  
Vascular Malformations ◽  
Low Flow ◽  
Complete Regression ◽  
Lymphatic Malformations ◽  
Interval Change ◽  
Radiologic Findings ◽  
Scale Scores ◽  
Complete Obliteration ◽  
Initial Imaging

Introduction : Lymphatic malformations (LMs) are low‐flow vascular malformations that arise as a result of erroneous vascular development during embryogenesis. Prior to the advent of the Berenstein‐De Leacy (BDL) scale, no reproducible grading system had been designed to compare sclerotherapy outcomes on the basis of radiologic findings. The soft‐tissue detail, absence of ionizing radiation, safety profile, and ubiquity of MR imaging made it an ideal technique on which the imaging‐based criteria was developed. The BDL scale ranges from 1–7 denoting complete obliteration to significant progression respectively. A “B” modifier is assigned for identification of granulation tissue in the treatment bed. We examine and validate the BDL scale on a cohort of 16 orbital LMs from our practice. Methods : Orbital LMs treated with sclerotherapy at our practice between 2000 and 2021 were assessed by an attending physician prior to initial and after final treatment to assign scale scores. The assigned scores represent changes in the orbit as defined by pre‐ and post‐septal spaces, above and below eyelids, and intra/extraconal spaces going to the coronal apex without the cavernous sinus. Results : The median age at initial imaging was 24 months (range: 1–445 months) and 108 months (range 12–528) at final imaging. The median imaging interval was 61 month. Males and females were represented in our cohort equally. Six cases presented with right orbital LMs (37.5%) and 10 presented on the left (62.5%). Six cases presented with macrocystic malformations (37.5%), five cases with microcystic (31.25%), and five cases with mixed (31.25%). 11 patients were treated with bleomycin and 5 patients were treated with bleomycin and doxycycline. BDL scale scores ranged from 2–7 with one case assigned the “B” modifier. Two cases were labelled as BDL7, or gross interval progression of the LM. Four cases were labelled as BDL6, or regression of the LM in one region with progression into a previously uninvolved/untreated area. Three cases were labelled as BDL5 with minimal or no gross interval change. One case was labelled as BDL4 and assigned the “B” modifier for partial regression with >50% estimated volume of residual malformation and granulation tissue in the treatment bed. Three cases were labelled as BDL3, or partial repression with <50% estimated volume of residual malformation. One case was labelled as BDL2 with near‐complete regression with trace residual of the lesion. No cases were labelled as BDL1, or complete regression of the lesion. Conclusions : The BDL scale was applied to a series of 16 orbital LMs to demonstrate its versatility in describing the treatment progression of this historically difficult‐to‐classify malformation. We hope visualization of BDL scores for orbital LMs will assist other interventionalists with incorporating this scale as a metric for treatment progression and outcomes.

scholarly journals Measuring Differential Volume Using the Subtraction Tool for Three-Dimensional Breast Volumetry: A Proof of Concept Study

2020 ◽  
pp. 155335062094556
Author(s):  
Faith Hyun Kyung Jeon ◽  
Michelle Griffin ◽  
Aurora Almadori ◽  
Jajini Varghese ◽  
Stephanie Bogan ◽  
...  
Keyword(s):  
Three Dimensional ◽  
Computer Software ◽  
Patient Positioning ◽  
Volumetric Analysis ◽  
Volumetric Assessment ◽  
Alternative Approach ◽  
Significant Difference ◽  
Actual Volume ◽  
Novel Method ◽  
The Subject

Background. Three-dimensional (3D) photography provides a promising means of breast volumetry. Sources of error using a single-captured surface to calculate breast volume include inaccurate designation of breast boundaries and prediction of the invisible chest wall generated by computer software. An alternative approach is to measure differential volume using subtraction of 2 captured surfaces. Objectives. To explore 3D breast volumetry using the subtraction of superimposed images to calculate differential volume. To assess optimal patient positioning for accurate volumetric assessment. Methods. Known volumes of breast enhancers simulated volumetric changes to the breast (n = 12). 3D photographs were taken (3dMDtorso) with the subject positioned upright at 90° and posteriorly inclined at 30°. Patient position, breathing, distance and camera calibration were standardised. Volumetric analysis was performed using 3dMDvultus software. Results. A statistically significant difference was found between actual volume and measured volumes with subjects positioned at 90° ( P < .05). No statistical difference was found at 30° ( P = .078), but subsequent Bland–Altman analysis showed evidence of proportional bias ( P < .05). There was good correlation between measured and actual volumes in both positions (r = .77 and r = .85, respectively). Univariate analyses showed breast enhancer volumes of 195 mL and 295 mL to incur bias. The coefficient of variation was 5.76% for single observer analysis. Conclusion. Positioning the subject at a 30° posterior incline provides more accurate results from better exposure of the inferior breast. The subtraction tool is a novel method of measuring differential volume. Future studies should explore methodology for application into the clinical setting.

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